Application—Contents.

An applicant for voter registration shall complete an application providing the following information concerning his or her qualifications as a voter in this state:

(1) The former address of the applicant if previously registered to vote;

(2) The applicant's full name;

(3) The applicant's date of birth;

(4) The address of the applicant's residence for voting purposes;

(5) The mailing address of the applicant if that address is not the same as the address in subsection (4) of this section;

(6) The sex of the applicant;

(7) The applicant's Washington state driver's license number, Washington state identification card number, or the last four digits of the applicant's social security number if he or she does not have a Washington state driver's license or Washington state identification card;

(8) A check box allowing the applicant to indicate that he or she is a member of the armed forces, national guard, or reserves, or that he or she is an overseas voter;

(9) A check box allowing the applicant to acknowledge that he or she is at least eighteen years old or is at least sixteen years old and will vote only after he or she reaches the age of eighteen;

(10) Clear and conspicuous language, designed to draw the applicant's attention, stating that the applicant must be a United States citizen in order to register to vote;

(11) A check box and declaration confirming that the applicant is a citizen of the United States;

(12) The following warning:

"If you knowingly provide false information on this voter registration form or knowingly make a false declaration about your qualifications for voter registration you will have committed a class C felony that is punishable by imprisonment for up to five years, a fine of up to ten thousand dollars, or both."

(13) The oath required by RCW 29A.08.230 and a space for the applicant's signature; and

(14) Any other information that the secretary of state determines is necessary to establish the identity of the applicant and prevent duplicate or fraudulent voter registrations.

This information shall be recorded on a single registration form to be prescribed by the secretary of state.